Thyroid Radiofrequency Ablation (RFA) : Presented By: Supervisor

Thyroid Radiofrequency Ablation
(RFA)
Presented by :
Supervisor :
INTRODUCTION
Nodular thyroid disease is a very common finding in clinical practice, discovered by
ultrasound (US) in about 50 % of the general population, with higher prevalence in
women and in the elderly
Nevertheless, large thyroid nodules may become responsible for pressure symptoms,
resulting in neck discomfort, cosmetic complaints, and decreased quality of life
Although surgery is widely available, highly effective, and safe in skilled centers,
complications (both temporary and permanent) still occur in 2–10 % of cases
Hypothyroidism is an unavoidable effect after total thyroidectomy, requiring lifelong L-

thyroxine replacement therapy.
INTRODUCTION (cont…)
The alternatives include ethanol ablation (EA) [11–13], radiofrequency ablation (RFA),
percutaneous laser ablation (PLA), highintensity focused ultrasound (HIFU), and
microwave ablation
(RFA) for thyroid lesions is a minimally invasive treatment modality that an alternative
to surgery in patients with benign thyroid nodules; it may also have an effective
complementary role in the management of recurrent thyroid cancers
Over the last two decades, nonsurgical, minimally invasive, US-guided techniques have
been proposed for the treatment of thyroid nodules
Other nonsurgical therapies, such as high-intensity focused-ultrasound (HIFU),

microwaves, cryotherapy, and electroporation, are presently under investigation
About Radiofrequency ablation…
volume shrinkage gradually occurs during

Radiofrequency (RF) induces thermal
the first months after treatment, when
injury into the target lesion by means of
necrotic tissue within nodule is
an alternating electric field, produced by
reabsorbed. Following one or more RF
an electrode needle connected to an
sessions, sometimes impressive, nodule
external radiofrequency generator. Tissue
size reduction (46–93 % in different
necrosis is achieved around the needle tip,
studies) is reached after 6 months and
through the heating induced by rapid ion
seems to be stable during a four-year
movement, in a controlled fashion
follow-up
About Radiofrequency ablation…
Thyroid function is not
affected by RF treatment, Hyperthyroidism caused by
and this is an important AFTN can be completely or
advantage as compared with at least partially cured by
surgery or radioiodine RF treatment.
therapy
In a recent large multicenter

study, the overall
complication rate for RF
treatment was 3.3 %, and
the major complication rate
was 1.4 %.
RFA PROCEDURE
The maximum temperature

RFA refers to hyperthermic Coagulative necrosis and at a distance of 5 mm from
ablation by high frequency irreversible damage is the RFA electrode was
alternating electric current induced near the electrode at between 44∘ C and 61∘ C
oscillating between 200 and temperature between 50∘ C while, at a distance of 10
1200 kHz and 100∘ C mm, a maximum
temperature of 53∘C
TECHNIQUE
• The electrode is a 14-gauge, 10cm long, four-hook expandable needle
• Each hook is recommended to be 10 mm away from thyroid capsule,
FIXED ABLATION 5∼6 mm from pseudocapsule of the outer edge of nodule, and 15mm
from heat-sensitive cervical structures.
TECHNIQUE • With this technique, a spherical ablative zone is usually achieved.
After the ablation, the hooks are retracted and the electrode is slowly
withdrawn after the RF energy has been switched off
• The electrode is usually 15cm in length and 17 gauge in size with 1

cm active tip
• The ablation first starts from the deepest layer up and so the electrode
MOVING SHOT
is slowly withdrawn to the surface. It is important that the region
TECHNIQUE close to the trachea esophageal groove be underablated in order to
avoid injury to the recurrent laryngeal nerve, trachea, and esophagus
as this area is often referred to as the “danger triangle”.
INDICATION RFA OF THYROID
LESION
Benign thyroid nodules/ Large
(volume >20 ml), nonfunctioning,
benign thyroid nodules in patients Autonomously functioning
presenting with local symptoms or thyroid nodules (AFTN)
cosmetic complaints when surgery
is contraindicated or decline
Recurrent thyroid cancers in

patients at high surgical risk
The above-mentioned indications are intended for solid or dominantly solid thyroid nodules.
LESION
Nonfunctioning, benign
thyroid nodules (even with
volume <20 ml) coupled
with early local discomfort
that significantly grow over
time
In this case, RF may be useful to strongly reduce nodule size to prevent its future growth, together with progressive
increase in symptoms and cosmetic concerns, and to avoid future thyroid surgery. The agreement for this indication was
not complete among experts because someone suggested that surgery is more advisable if thyroid nodules seem to be fast-
growing. Although nodule growth speed is not considered to be a significant marker for malignancy, for which FNA
repeat is recommended to rule out the risk of malignancy, before RF treatment can be proposed.
LESION
Thyroid cysts and
Primary thyroid
dominantly cystic
cancers or follicular
thyroid nodules (-):
neoplasms (-): surgery
PEI is first-line
is standard therapy
treatment.
The following discussed indications for RF ablation were not accepted

CLINICAL
EFFICACY
RFA
Table 1 shows
the results of
volume
reduction of
cold thyroid
nodule after
RFA
Table 1 results
For cold nodules, the efficacy of RFA has mainly been evaluated in terms of reduction of nodule volume,
pressure symptoms, and cosmetic symptoms.
The reported mean volume reductions at 1- and 6-month were 33∼53% and 51∼92%, respectively
In this study, 20 patients were assigned to the RFA group while the other 20 patients to the control group.
After 12 months, patients in the RFA group had significantly decreased mean nodule size (13.3 to 1.8 mL, 𝑃
< 0.001) while, in the control group, the mean nodule size was nearly static (11.2 to 11.8 mL, 𝑃 > 0.05)
The symptom score was also significantly improved in the RFA group (3.4 to 0.6 out of 6, 𝑃 < 0.001) and
there was a trend of worsening symptoms in the control group (3.0 to 4.1 out of 6, 𝑃 > 0.05)
CLINICAL
EFFICACY RFA Table 2 shows the result in patients underwent RFA
for hyperfunctioning thyroid nodule
Table 2 results
For benign hyperfunctioning thyroid nodules, RFA not only reduces the volume but also
improves the functional status
The majority has improved thyroid function and reduced the need for antithyroid medication
Relative to cold nodules, ablation of hyperfunctioning thyroid nodules achieves lower volume
reduction (60% versus 76% at 12 month) and requires more number of sessions
The symptom score was also significantly improved in the RFA group (3.4 to 0.6 out of 6, 𝑃 <
0.001) and there was a trend of worsening symptoms in the control group (3.0 to 4.1 out of
6, 𝑃 > 0.05)
COMPLICATION
PAIN VOICE CHANGE NODULE RUPTURE OTHERS
• usually transient and • due to laryngeal • Nodule rupture may • Skin burn
mild, is the most dysfunction is reported, occur 1 month after • Hematoma
frequent side effect although very rare, and RFA • Thyrotoxicosis
during procedure may be prevented • It usually presents as a • Tracheal and
• However, it is usually paying special attention sudden neck bulging esophageal injury
self-limiting and when the treatment is and pain at the time of • Brachial plexus injury
resolved soon when the performed in nodular rupture.
power of RFA has been tissue close to • It is caused by
switched off laryngeal nerve breakdown of thyroid
• It is likely caused by capsule and internal
thermal injury to bleeding
recurrent laryngeal
nerve or sometime
vagal nerve in case of
large thyroid nodul
CONCLUSION
Radiofrequency ablation and other nonsurgical, minimally invasive, US-guided techniques may play
an important role in the management of nodular thyroid disease
RFA appears to be an effective nonsurgical option to improve pressure and toxic symptoms in
biopsy-proven benign thyroid nodules
The main weaknesses of using RFA on the thyroid gland are several folds and they include the
lack of definitive histology, possibility of incomplete nodule ablation, and surveillance problems
for the residual thyroid mass after RFA
Preliminary reports showed satisfactory results in volume reduction, pressure symptoms, and
cosmetic symptoms, and these results appear to be sustained in the long term
Therefore, proper selection of patient with benign nodule for RFA and subsequent monitoring were
needed
REFERENCE
1. Garberoglio R, Aliberti C, Appetecchia M, Attard M. Radiofrequency ablation for
thyroid nodules : which indications ? The first Italian opinion statement. J
Ultrasound. 2015;18(4):423–30.
2. Wong K, Lang BH. Use of Radiofrequency Ablation in Benign Thyroid Nodules :
A Literature Review and Updates. 2013;2013.
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Thyroid Radiofrequency Ablation

Hypothyroidism is an unavoidable effect after total thyroidectomy, requiring lifelong L-

Other nonsurgical therapies, such as high-intensity focused-ultrasound (HIFU),

volume shrinkage gradually occurs during

In a recent large multicenter

The maximum temperature

• The electrode is usually 15cm in length and 17 gauge in size with 1

Recurrent thyroid cancers in

The following discussed indications for RF ablation were not accepted

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